Maternal Newborn Nursing Test Neonatal Assessment and Immediate Care 1 — Questions and Answers
Question 1: A nurse assesses a newborn at 1 minute and assigns an Apgar score. The infant has a heart rate of 98 bpm, weak cry, some flexion of extremities, grimace to stimulation, and a pink body with blue extremities. What is the Apgar score?
Correct answer: 6
HR <100 = 1, weak cry (slow, irregular respirations) = 1, some flexion = 1, grimace = 1, pink body/blue extremities (acrocyanosis) = 1, totaling 6.
Question 2: Which assessment finding in a newborn at 24 hours of life requires immediate provider notification?
- Respiratory rate of 68 breaths per minute with grunting (Correct answer)
- Respiratory rate of 40 breaths per minute
- Acrocyanosis of the hands and feet
- Passage of meconium stool
Correct answer: Respiratory rate of 68 breaths per minute with grunting
A respiratory rate >60 breaths per minute with grunting indicates respiratory distress and requires immediate provider notification to evaluate for infection or respiratory pathology.
Question 3: A nurse notes a newborn's axillary temperature is 36.1°C (97°F) at 2 hours of life. What is the priority intervention?
- Place the newborn under a radiant warmer and reassess in 30 minutes (Correct answer)
- Administer warm IV fluids
- Notify the provider immediately for sepsis workup
- Encourage skin-to-skin contact with the mother only
Correct answer: Place the newborn under a radiant warmer and reassess in 30 minutes
Neonatal hypothermia (temperature <36.5°C) is managed initially by placing the infant under a radiant warmer to restore normothermia and prevent metabolic complications.
Question 4: When assessing the anterior fontanel of a newborn, which finding is abnormal?
- Bulging and tense fontanel in a quiet, non-crying infant (Correct answer)
- Soft and flat fontanel
- Fontanel that slightly bulges when the infant cries
- Diamond-shaped fontanel measuring 2 × 2 cm
Correct answer: Bulging and tense fontanel in a quiet, non-crying infant
A bulging, tense fontanel in a quiet infant suggests increased intracranial pressure due to conditions such as hydrocephalus, meningitis, or intracranial hemorrhage.
Question 5: Which reflex is assessed by stroking the lateral aspect of the sole of the newborn's foot from heel to toe, resulting in dorsiflexion of the big toe and fanning of other toes?
- Babinski reflex (Correct answer)
- Stepping reflex
- Moro reflex
- Rooting reflex
Correct answer: Babinski reflex
The Babinski reflex (plantar reflex) is elicited by stroking the lateral sole; dorsiflexion of the great toe and toe fanning is a normal finding in newborns due to immature corticospinal tracts.
Question 6: A nurse assesses a newborn's blood glucose 30 minutes after birth. The result is 38 mg/dL. What should the nurse do first?
- Initiate early feeding (breast or formula) and recheck glucose in 30–60 minutes (Correct answer)
- Administer IV dextrose immediately
- Report the finding to the provider and await orders before acting
- Document the finding as normal and continue routine care
Correct answer: Initiate early feeding (breast or formula) and recheck glucose in 30–60 minutes
A blood glucose <47 mg/dL in a newborn is hypoglycemia; the first-line treatment is early oral feeding, followed by retesting to confirm response before escalating to IV dextrose.
